Home Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum
Article
Licensed
Unlicensed Requires Authentication

Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum

  • Jane Rowat and Manish Suneja EMAIL logo
Published/Copyright: September 12, 2022
Diagnosis
From the journal Diagnosis Volume 9 Issue 4

Abstract

Objectives

The acquisition of clinical reasoning (CR) skills is essential for future healthcare providers as they advance through their education. There is growing consensus that CR skills should be longitudinally integrated into undergraduate curriculum for acquisition/application of these skills. However, only a minority of schools reported having CR focused teaching sessions, citing a lack of curricular time and faculty expertise as the largest barriers. We describe the design and implementation of this theme and report the effects of its early introduction in Phase One as measured by the Diagnostic Thinking Inventory (DTI).

Methods

The Carver College of Medicine developed and implemented a longitudinal four-year clinical reasoning theme (CRT) with a special emphasis on introducing concepts in the preclinical years (Phase One). Educational strategies used to implement the theme relied on following principles: 1) new skills are best acquired in context of application; 2) contextual learning stimulates transfer of knowledge; and 3) knowledge of pathophysiology is necessary but alone is not sufficient to develop CR skills. A patient-centered CR schema served as the framework for developing the theme. Specific focus areas, pedagogies and assessment strategies were established for each of the three phases.

Results

The cohort with CRT demonstrated a significant increase in total DTI score after theme implementation compared to the cohort without.

Conclusions

A formal 4-year longitudinal CR theme is feasible, allowing for integration of pathophysiology, social determinants of health, and clinical skills. Early introduction of CR concepts as assessed by DTI showed improvement in student reasoning skills post-intervention.

Keywords: clinical reasoning; diagnostic thinking inventory; longitudinal curriculum; undergraduate medical education
Corresponding author: Manish Suneja, MD, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA, Phone: 1-319-3561616, E-mail:

  1. Research funding: Not applicable.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: All authors report no conflicts of interest relevant to this article.

  4. Informed consent: Not applicable.

  5. Ethical approval: This study was approved by the Institutional Review Board at the University of Iowa.

References

1. Bowen, JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med 2006;355:2217–25. https://doi.org/10.1056/nejmra054782.Search in Google Scholar

2. Englander, R, Cameron, T, Ballard, AJ, Dodge, J, Bull, J, Aschenbrener, CA. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med 2013;88:1088–94. https://doi.org/10.1097/acm.0b013e31829a3b2b.Search in Google Scholar

3. Gay, S, Bartlett, M, McKinley, R. Teaching clinical reasoning to medical students. Clin Teach 2013;10:308–12. https://doi.org/10.1111/tct.12043.Search in Google Scholar PubMed

4. Rencic, J, Trowbridge, RLJr., Fagan, M, Szauter, K, Durning, S. Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. J Gen Intern Med 2017;32:1242–6. https://doi.org/10.1007/s11606-017-4159-y.Search in Google Scholar PubMed PubMed Central

5. Norman, G. Research in clinical reasoning: past history and current trends. Med Educ 2005;39:418–27. https://doi.org/10.1111/j.1365-2929.2005.02127.x.Search in Google Scholar PubMed

6. Monteiro, SM, Norman, G. Diagnostic reasoning: where we’ve been, where we’re going. Teach Learn Med 2013;25:S26–32. https://doi.org/10.1080/10401334.2013.842911.Search in Google Scholar PubMed

7. Rencic, J. Twelve tips for teaching expertise in clinical reasoning. Med Teach 2011;33:887–92. https://doi.org/10.3109/0142159x.2011.558142.Search in Google Scholar

8. Young, ME, Dory, V, Lubarsky, S, Thomas, A. How different theories of clinical reasoning influence teaching and assessment. Acad Med 2018;93:1415. https://doi.org/10.1097/acm.0000000000002303.Search in Google Scholar PubMed

9. Eva, KW. What every teacher needs to know about clinical reasoning. Med Educ 2005;39:98–106. https://doi.org/10.1111/j.1365-2929.2004.01972.x.Search in Google Scholar PubMed

10. Khin-Htun, S, Kushairi, A. Twelve tips for developing clinical reasoning skills in the pre-clinical and clinical stages of medical school. Med Teach 2019;41:1007–11. https://doi.org/10.1080/0142159x.2018.1502418.Search in Google Scholar

11. Schmidt, HG, Mamede, S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ 2015;49:961–73. https://doi.org/10.1111/medu.12775.Search in Google Scholar PubMed

12. Cooper, N, Bartlett, M, Gay, S, Hammond, A, Lillicrap, M, Matthan, J, et al.. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education. Med Teach 2021;43:152–9. https://doi.org/10.1080/0142159x.2020.1842343.Search in Google Scholar

13. Olson, A, Rencic, J, Cosby, K, Rusz, D, Papa, F, Croskerry, P, et al.. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosis (Berl) 2019;6:335–41. https://doi.org/10.1515/dx-2018-0107.Search in Google Scholar PubMed

14. Kononowicz, AA, Hege, I, Edelbring, S, Sobocan, M, Huwendiek, S, Durning, SJ. The need for longitudinal clinical reasoning teaching and assessment: results of an international survey. Med Teach 2020;42:457–62. https://doi.org/10.1080/0142159x.2019.1708293.Search in Google Scholar PubMed

15. Kern, DETP, Hughes, MT. Curriculum development for medical education: a six-step approach, 2nd ed. Baltimore, MD: The John’s Hopkins University Press; 2009.Search in Google Scholar

16. Bordage, G, Grant, J, Marsden, P. Quantitative assessment of diagnostic ability. Med Educ 1990;24:413–25. https://doi.org/10.1111/j.1365-2923.1990.tb02650.x.Search in Google Scholar PubMed

17. Custers, EJ. Thirty years of illness scripts: theoretical origins and practical applications. Med Teach 2015;37:457–62. https://doi.org/10.3109/0142159x.2014.956052.Search in Google Scholar PubMed

18. Lubarsky, S, Dory, V, Audetat, MC, Custers, E, Charlin, B. Using script theory to cultivate illness script formation and clinical reasoning in health professions education. Can Med Educ J 2015;6:e61–70. https://doi.org/10.36834/cmej.36631.Search in Google Scholar

19. Mamede, S, Schmidt, HG. The structure of reflective practice in medicine. Med Educ 2004;38:1302–8. https://doi.org/10.1111/j.1365-2929.2004.01917.x.Search in Google Scholar PubMed

20. Mamede, S, van Gog, T, Moura, AS, de Faria, RM, Peixoto, JM, Rikers, RM, et al.. Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Med Educ 2012;46:464–72. https://doi.org/10.1111/j.1365-2923.2012.04217.x.Search in Google Scholar PubMed

21. Kassirer, JP. Teaching clinical reasoning: case-based and coached. Acad Med 2010;85:1118–24. https://doi.org/10.1097/acm.0b013e3181d5dd0d.Search in Google Scholar PubMed

22. Lomis, K, Amiel, JM, Ryan, MS, Esposito, K, Green, M, Stagnaro-Green, A, et al.. Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC core entrustable professional activities for entering residency pilot. Acad Med 2017;92:765–70. https://doi.org/10.1097/acm.0000000000001543.Search in Google Scholar

23. Croskerry, P. A universal model of diagnostic reasoning. Acad Med 2009;84:1022–8. https://doi.org/10.1097/acm.0b013e3181ace703.Search in Google Scholar PubMed

24. Ferguson, KJ, Kreiter, CD, Haugen, TH, Dee, FR. Web-enabled mechanistic case diagramming: a novel tool for assessing students’ ability to integrate foundational and clinical sciences. Acad Med 2018;93:1146–9. https://doi.org/10.1097/acm.0000000000002184.Search in Google Scholar PubMed

25. Ferguson, KJ, Kreiter, CD, Franklin, E, Haugen, TH, Dee, FR. Investigating the validity of web-enabled mechanistic case diagramming scores to assess students’ integration of foundational and clinical sciences. Adv Health Sci Educ Theory Pract 2020;25:629–39. https://doi.org/10.1007/s10459-019-09944-y.Search in Google Scholar PubMed

26. Harris, KI, Rowat, JS, Suneja, M. Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach. Diagnosis (Berl) 2020;7:21–5. https://doi.org/10.1515/dx-2019-0023.Search in Google Scholar PubMed

27. Tavakol, M, Dennick, R. Making sense of Cronbach’s alpha. Int J Med Educ 2011;2:53–5. https://doi.org/10.5116/ijme.4dfb.8dfd.Search in Google Scholar PubMed PubMed Central

28. Connor, DM, Durning, SJ, Rencic, JJ. Clinical reasoning as a core competency. Acad Med 2020;95:1166–71. https://doi.org/10.1097/acm.0000000000003027.Search in Google Scholar PubMed

29. Ericsson, KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:S70–81. https://doi.org/10.1097/00001888-200410001-00022.Search in Google Scholar PubMed

30. Kerfoot, BP, DeWolf, WC, Masser, BA, Church, PA, Federman, DD. Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial. Med Educ 2007;41:23–31. https://doi.org/10.1111/j.1365-2929.2006.02644.x.Search in Google Scholar PubMed

31. Simpkin, AL, Vyas, JM, Armstrong, KA. Diagnostic reasoning: an endangered competency in internal medicine training. Ann Intern Med 2017;167:507–8. https://doi.org/10.7326/m17-0163.Search in Google Scholar PubMed

32. Sobral, DT. Diagnostic ability of medical students in relation to their learning characteristics and preclinical background. Med Educ 1995;29:278–82. https://doi.org/10.1111/j.1365-2923.1995.tb02849.x.Search in Google Scholar PubMed

33. Sobral, DT. An appraisal of medical students’ reflection-in-learning. Med Educ 2000;34:182–7. https://doi.org/10.1046/j.1365-2923.2000.00473.x.Search in Google Scholar PubMed

34. Groves, M, Scott, I, Alexander, H. Assessing clinical reasoning: a method to monitor its development in a PBL curriculum. Med Teach 2002;24:507–15. https://doi.org/10.1080/01421590220145743.Search in Google Scholar PubMed

35. Gehlhar, K, Klimke-Jung, K, Stosch, C, Fischer, MR. Do different medical curricula influence self-assessed clinical thinking of students? GMS Z Med Ausbild 2014;31:Doc23.Search in Google Scholar

36. Findyartini, A, Hawthorne, L, McColl, G, Chiavaroli, N. How clinical reasoning is taught and learned: cultural perspectives from the University of Melbourne and Universitas Indonesia. BMC Med Educ 2016;16:185. https://doi.org/10.1186/s12909-016-0709-y.Search in Google Scholar PubMed PubMed Central

37. Augustin, RC, Simonson, MG, Rothenberger, SD, Lalama, C, Bonifacino, E, DiNardo, DJ, et al.. The use of podcasts as a tool to teach clinical reasoning: a pseudorandomized and controlled study. Diagnosis (Berl) 2022;9:323–31. https://doi.org/10.1515/dx-2021-0136.Search in Google Scholar PubMed

38. Augustin, RC, Bonifacino, E, Tilstra, SA. Morning Report for all: the use of podcasts to disseminate clinical reasoning tools. Med Educ 2019;53:1150. https://doi.org/10.1111/medu.13964.Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/dx-2022-0046).

Received: 2022-05-10
Accepted: 2022-08-12
Published Online: 2022-09-12

© 2022 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Review
  3. Diagnostic and therapeutic approach to hypernatremia
  4. Opinion Papers
  5. The diagnostic potential and barriers of microbiome based therapeutics
  6. Pursuit of “endpoint diagnoses” as a cognitive forcing strategy to avoid premature diagnostic closure
  7. Guidelines and Recommendations
  8. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy
  9. Original Articles
  10. Exploring procedure-based management reasoning: a case of tension pneumothorax
  11. A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts
  12. Human centered design workshops as a meta-solution to diagnostic disparities
  13. Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum
  14. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning
  15. Evolution of throat symptoms during the COVID-19 pandemic in the US
  16. Evaluating the role of a fully automated SARS-CoV-2 antigen ECLIA immunoassay in the management of the SARS COV 2 pandemic on general population
  17. miR-21-3p and miR-192-5p in patients with type 2 diabetic nephropathy
  18. Letter to the Editors
  19. Convoluted molecular maze of neprilysin
  20. OPeNet: an AI-based platform implemented to facilitate clinical reasoning by primary care practitioners, as well as the virtuous co-management of chronic patients during and after the COVID-19 pandemic in Italy
  21. Letter to the Editor in reply to Diamandis “COVID-19 and the Le Chatelier’s principle”
https://doi.org/10.1515/dx-2022-0046
Keywords for this article
clinical reasoning; diagnostic thinking inventory; longitudinal curriculum; undergraduate medical education

Articles in the same Issue

  1. Frontmatter
  2. Review
  3. Diagnostic and therapeutic approach to hypernatremia
  4. Opinion Papers
  5. The diagnostic potential and barriers of microbiome based therapeutics
  6. Pursuit of “endpoint diagnoses” as a cognitive forcing strategy to avoid premature diagnostic closure
  7. Guidelines and Recommendations
  8. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy
  9. Original Articles
  10. Exploring procedure-based management reasoning: a case of tension pneumothorax
  11. A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts
  12. Human centered design workshops as a meta-solution to diagnostic disparities
  13. Longitudinal clinical reasoning theme embedded across four years of a medical school curriculum
  14. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning
  15. Evolution of throat symptoms during the COVID-19 pandemic in the US
  16. Evaluating the role of a fully automated SARS-CoV-2 antigen ECLIA immunoassay in the management of the SARS COV 2 pandemic on general population
  17. miR-21-3p and miR-192-5p in patients with type 2 diabetic nephropathy
  18. Letter to the Editors
  19. Convoluted molecular maze of neprilysin
  20. OPeNet: an AI-based platform implemented to facilitate clinical reasoning by primary care practitioners, as well as the virtuous co-management of chronic patients during and after the COVID-19 pandemic in Italy
  21. Letter to the Editor in reply to Diamandis “COVID-19 and the Le Chatelier’s principle”
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 27.9.2025 from https://www.degruyterbrill.com/document/doi/10.1515/dx-2022-0046/html
Scroll to top button